As part of Africa Live's look at the issue, and some of the associated problems, top African psychiatrist Dr Frank Njenga answers your questions.

Betsy, USA, Nebraska

I am diagnosed bipolar, and I was wondering how psychosis or visions are normally dealt with in traditional African societies. I know there must be a lot of variation, but, from what I have read, it is typical, or a lot more "normal" for individuals in 3rd world countries to suffer nervous breakdowns, and then recuperate and go back to normal functioning.

Also, in various Native American traditions visions are used as guiding forces driving the aim of ritual behaviour and society..something most Americans would frown on, the possibility that there is latent power in the birth of the subconscious. Some doctors believe in letting psychotic episodes run their course, others (most) simply medicate and ask us to forget what we have seen.

Could you discuss how we can merge the humanistic perspecitve with the medicalized, in order to preserve the possibility of recognizing the cultural and/or spiritual factors at work here?

Dr Njenga:

Yours is a most interesting and complex question, mainly because of the many issues you raise. Also, Africa is a large, complex and variable continent of many different cultures and practices.
It is however possible that some psychotic illnesses have a better prognosis in Africa, perhaps as you say because of a more accommodating way of life in rural Africa. It could also be due to the different causation of the psychosis. We simply do not have enough doctors from Africa.
Just to complicate things, our experience is that psychosis in general (bipolar and schizophrenia as examples) have more in common all over the world than there are differences in the psychosis. A very famous African psychiatrist (Prof Lambo) wrote about the pathoplasticity of culture, by which he meant the effect of culture on the expression of psychosis which remains psychosis.
You may wish to read more on this subject in a book I recently edited, authored by the leading psychiatrists in the African continent. It is published by Masson.
Michael, Kenya

Are there any doctors who practice clinical hypnotherapy in Kenya?
Dr Njenga:

There are no doctors who practice clinical hypnotherapy in Kenya.

Kotelo,
Lesotho

I once smoked marijuana and experienced very bad mood and hallucinations which lasted for a long time. I never underwent any psychatric treatment, but I suspect this may affect my life in the later stage because i have a fear of going crazy .

Dr Njenga:

A single encounter with Marijuana is unlikely to affect you in the long term. New and emerging evidence does however indicate a link between psychosis and the longterm use of Marijuana particularly in young people where it has been linked with the onset of the mental illness Schizophrenia.

This is a serious mental illness that affects young people of all races and whose chief clinical features include delusions (false beliefs) and hallucinations.

Though treatable, it can in some cases run a chronic course that might interfere with one's ambitions in life.

Dr John Turner, England

To what degree do you believe the impact of long term sleep depravation due to stress will effect ones ability of "normal" social interaction?
Asante sana.

Dr.Njenga:

Long term sleep deprivation can lead to serious physical, emotional and psychological consequences. More importantly, if not determined, the cause of the stress that lead to lack of sleep in the first instance can, of itself have serious consequences. It is therefore important not only to get to sleep but also to find and solve the cause of the stress.

Sleep is important because it is the restorative stage in the life of an animal. In man, it occupies about 30% of one's lifetime. It is during these times that the body (and mind) rebuilds itself. Children grow during sleep.

Deprived of sleep, a person will die in four to six days. Before then, one would experience difficulties with concentration, would experience visual hallucinations, and extreme nervousness.

Good sleep hygiene includes the setting up of a waking up time, determination of an individual's sleep requirements, and the avoidance of among other things late evening exercise, daytime TV and naps, and for some, alcohol. Relaxation exercise and a hot milky drink can help one sleep better.

All in all however, find the cause of the stress and as much as one can, avoid sleeping pills and use them only under medical supervision.

Sandy Kamanda, Sierra Leone Dr.Njenga. Back in my country one of the major social problems we face is "mad people" in the streets. I feel really sorry for them. How best can our government assist these people. Does being crazy mean the end? Or some of them may be cured?

Dr.Njenga:
A country that is unable to look after the most vulnerable members of its society must stand condemned. It is not enough to feel sorry for persons who suffer mental disorder and certainly it is inadequate for you to expect the government on its own to look after persons with mental illness. The management of such persons is a collaborative action between government and civil society including non-governmental organizations dealing with social issues The World Psychiatric Association program on stigma on mental health is an example of a global approach aimed at meeting the needs of global citizens in the eradication of stigma. The programme can be accessed through the following website: wwww.openthedoors.com. It forms very interesting reading.

A Simen , Canada
I have a personal question, and I really want your advice.
I am a 27 year old male, currently studying engineering in a Canadian university. My problem is, that there is nothing that makes me happy. I keep having a dream which has been with me since I was 10, to do something extraordinary which will benefit the whole of humanity. I know I am gifted but trying to implement or find out what I can do, I can't successful in my day today life, because it is so boring. There is nothing new in it and I can't get the inspiration. Do you think I have a problem?

Dr.Njenga:
It is possible that you have a problem. Depression at the age of 27 could give you the kind of feelings that you describe. You state that nothing makes you happy that you feel bored and that you lack any inspiration. Only examination by a qualified practitioner could elicit for you if any other symptoms exist that may lead to clinical diagnosis of depression. The fact that you are in your view gifted and would like to do something extraordinary in your life does not in itself protect you from developing a depressive illness. Remember in this regard that a number of great men including Sir Winston Churchill and Abraham Lincoln suffered major depression. There is therefore no contradiction in having both depression and achieving extra-ordinary success in life.

George Werner, USA/Liberia
What is being done about adult mental health challenges in post-war countries such as Liberia and Sierra Leone? What about leaders, such as Charles Taylor, whose mental problems may be hampering the way they lead their people?

Thanks for the opportunity to ask these questions. It is important to help children deal with trauma in a post-war situation, but it seems to me adults forget that they, too, need help.

Dr.Njenga:
One of the most important and tragic, consequences of war and its effect on special groups including children and the elderly. In the middle of a war, however, little attention is paid by the combatants to the mental health consequences of their wars. The World Psychiatric Association has recognized this reality and issued special guidelines to Psychiatrists. In this respect your attention is drawn to the World Psychiatric Association publication for the year 2003 regarding the view of psychiatrists on the middle east easily accessible via the WPA website - www.wpanet.org.

Thoko, Zimbabwean in U.S.A
Growing up in both Zambia and then Zimbabwe, I can attest that people who had mental health problems were often shunned and castigated. As a professional how have you been able to accommodate some of the cultural taboos and advances made by western countries in providing the best possible mental health care in Africa. Secondly with all the other health problems that we are dealing like AIDS and Malaria how hard is it to convince African governments to allocate more funds for mental health, and how do you see the future of mental health-care delivery in the future?

Dr.Njenga:
The interface between traditional African practices (in mental health) and the practice of modern western medicine is an exciting though sometimes dangerous area. It is prone to much speculative discussion devoid of supportive evidence.
There is no doubt that there are many beneficial traditional African practices that were and still are preventive and primitive in the mental health area. Many mental disorders continue to be treated by traditional health practitioners who are the only practitioners available to the majority in rural Africa.

The challenge to most African governments is to harmonise the traditional practices with the modern methods. Traditional practititioners need to be trained and to learn the signs and symptoms of those diseases for which they have no skills. Equally western trained doctors need to learn areas in which their skills are inappropriate, as treatment modalities. In the development of mental health policies in African countries, it is imperative to take account of the skills of traditional healers, as well as the limitations of western medical practices including their availability in rural Africa.
There are many instances where Africans go for treatment in western hospitals, but must also go to the traditional healers for the cure, after all, all diseases have causes and until one finds the cause, the cure would remain elusive.
Mental Health is the Cinderella of medicine all over the world, much more so in Africa where malaria, AIDS and diarrhoeal diseases are much more dramatic in the way they cause death and destruction to Africans. Little attention is paid to the fact that AIDS is basically behavioural in origin and that suicide is as important a cause as road accidents. Depression is a leading cause of death and disability in the world, and Africa is no exception. That policymakers seem unaware of these facts only goes to compound the problem.

kehleboe Gongloe,
Liberian in the USA
I am a Liberian working in Philadelphia in the USA as Therapeutic staff. I implement a set of interventions in the classroom for kids diagnosed either as Attention Deficit Disorder. However, in recent years, some of these kids have been taken to Kenya and the story is that these kids improved without the medication and having access to one-on-one Therapeutic staff. Does the environment play any role in mental health?

Dr.Njenga :

Helene Pastors, South African in Belgium When I was a political prisoner in apartheid SA, for 8 months they kept me on 24 hour surveillance by video camera; then, to step up the pressure, they very visibly installed a microphone and reacted to whatever they heard on it. Things got very bad and I landed in a psychiatric hospital. Now I am writing a book about the whole experience.

My question is, did they want to induce schizophrenia or something else? What is the psychological effect of feeling constantly under surveillance like that? Perhaps I should add the cell was also sound proofed and there was no daylight, just a very weak bulb that was on day and night. I am currently living in Belgium but about to return to SA for the first time and feeling a bit nervous about facing the memories, especially those I still don't understand.

Dr. Njenga:
The use of sensory deprivation as a tool of torture has been used over the years by oppressive regimes in South America, Africa and Europe. The methods you describe are intended to break the spirit. By pressurizing and stressing a political opponent, the pressure is intended to either extract information or simply cause a break down in the resolve of his opponents. This would seem to have been the intention of the apartheid regime in respect to yourself.

You raise two different issues. First, the long-term consequences of torture and secondly, what happens when you get back to the land of your former torturers? With regard to the former, some people best exemplified by your former President Nelson Mandela seem exceptionally resilient to the most severe forms of pressure while others suffer longer term psychiatric illness. For those pre-disposed to the development of schizophrenia, this can be a possible outcome of prolonged stress of the type that you describe.

Depending on which City you are going to settle in, in South Africa, you may which to contact Prof. Robin Emsley at the University of Stellenbosch who is the current Secretary of the Association of African Psychiatrists who has a large data bank containing the names and addresses of psychiatrists within and outside South Africa.

Ngamia, Tanzania.
I want know about BIPOLAR depression

Dr. Njenga:
There are several interesting books written on the subject of bipolar disorder. In simple terms, it is a condition that is characterized by extreme mood swings alternating between extreme happiness and excitement with the very opposite which is the suffering of periods of extreme depression occasionally associated with suicidal thoughts. In between these attacks an individual can perform perfectly well in his or her life.

A number of famous men including Winston Churchill, are recorded as having suffered this disorder during a manic phase as characterized in some instances by exceptional artistic creativity in some instances business genius. Sadly, either many of the gains made during the highs are lost during the desperate periods of sadness characterized by extreme feelings of hopelessness and lack of self worth.
It is in these states that some people commit suicide.

Bipolar disorder sometimes runs in families, and is thought to be due to abnormalities in the distribution of chemical substances in the body. It is now fairly easily treated using a variety of drugs including Lithium and Sodium Valproate. Though severe, this is one of the mental illnesses that carry with it an excellent outcome if diagnosed and treated early.

Mr. Blake Bartrand, USA.
I am American currently residing in Thailand. I spent two years in the Peace Corps Kenya in 1996 and I'm now 53. I spent last year working as mental health worker at Forest View Psychiatric hospital in the USA. I worked with adolescents as well as adult female trauma victims, doing counselling and running group therapy sessions. Do you know of any volunteer or paying positions for someone willing to come back to Africa to be able to participate in? My Swahili is a little rusty after 4 years but not too bad.

Dr. Njenga:
Africa is a terribly traumatized continent as evidenced by the terrorist bomb blast in the City of Mombasa recently. In response to such catastrophes, frequent mental health workers often find themselves over-stretched because they have so many other duties and responsibilities not only arising from traumatic events among the population but also arising from other mental disorders. In absolute terms, Africa has a severe shortage of mental health workers and many countries in Africa have for example less than one Psychiatrist per million of the population. Some countries have no Psychiatrist whatsoever. I'm not suggesting that Psychiatrists are the only mental health workers required.

Africa is always prepared to welcome qualified, well meaning mental health workers who may or may not be able to speak local languages and who need not be Psychiatrists. Their primary qualification is a willingness to be of assistance preferably without expectation of pay because an average African lives on less than a dollar per day. You may get in touch through this website and I will be happy to assist you to get in touch with an appropriate local project that I am sure would benefit from your kindness.

Dr. Nkule Laibuta, Slovenia.
What is the current situation as far as the diagnosis and treatment of depression, anxiety and post traumatic stress disorders is concerned. I ask this in relation to the growing elections violence in Kenya. As far as I know you are more in the private sector. How is depression and anxiety and PTSD handled in public psychiatric institutions or general hospitals?

Dr. Njenga:
Kenya is emerging as one of the few African countries able to manage transition from one system of government to another. Following the death of President Jomo Kenyatta in 1978, President Moi took over and will retire at the end of 2002 following the forthcoming general election. There have been assorted incidences of politically related violence but nothing close to the politically instigated violence witnessed in the first multi-party election in 1992 and repeated at a subsequent election in 1997.

In a practical sense therefore, current events are unlikely to create much international displacement and are certainly unlikely to cause the severe PTSD that followed organized politically motivated violence that rocked most of the country. Most of these people are yet to receive any form of psychological help mainly because of the severe shortage of mental health workers in both the private and public institutions. Both sides however work very closely together as evidenced by an ongoing mental health project partly funded by DFID and implemented by the Government of Kenya's, Division of Mental Health and Kenya's Psychiatric Association consisting mainly of Psychiatrists in private practice.

Allan Njenga, United Kingdom
I was just wondering how they are doing in Africa with the stigma there is about mental health? I know Dr Njenga has been working hard on this subject trying to inform the people about mental illness.

Dr. Njenga:
The question of stigma and mental health has occupied and preoccupied most major national and international organizations working in the mental health area.

The most comprehensive anti-stigma campaign is currently run by the World Psychiatric Association (WPA) under the title, 'Open The Doors".

I would urge you to visit this most comprehensive website to obtain some insight into some of the activities that are going on world wide and you might even find some activities going on in your own country.

Briefly however, the WPA is using the mental disorder of Schizophrenia, as an example of a condition that attracts much stigma and prejudice largely because of the ignorance of various world communities.

By empowering different local organizations the world over and by using innovative methods of community education and advocacy, millions of people with mental illness are unable to come out and discuss their own experiences of stigma.

We see the current BBC program on mental health in Africa as an important and integral part of this much wider educational program that will inevitably go on for a number of years.

Any person able and willing to help in the war against the stigmatisation of mental illness is welcome to contact their local mental health association directly or through us.

Abbas Daramy-Bassey, an African in the UK

The untimely change of governments and other forms of power struggle creates a lot of distress for innocent people, sometimes resulting in mental illness. 'Displaced' people top the list of mentally ill people. The question is if there should be guidelines about political struggle similar to the Geneva Convention in the so-called rebel wars?.

Dr. Njenga:
Africa is in every respect a traumatized continent. The trauma in Africa arises from both natural and manmade disasters. In the latter category, wars between countries, civil wars and other causes of violence have caused Africa to host in excess of 6.5 million refugees.

Africa has to carry the additional burden of high levels of mental disorder commonly associated with poverty and displacement. Among these are Post Traumatic Stress Disorder (PTSD) and Depression.

Questions have been asked with regard to how Africa is preparing herself to deal with these emerging epidemics. There is no doubt that conditions like PTSD are not only recognizable, but are also to some extent treatable using currently available methods including drug therapy which is beyond the pockets of the majority of Africans.
Less expensive and more traditional methods of treating PTSD, is a matter for African scientists to explore.

As to whether guidelines should exist along the Geneva Convention with regard to conflicts in Africa, I hope that the African Union will address the root cause of violence in Africa and will find time and resources to deliberate fully on this question. As to whether violence causes culturally-specific consequences, no formal studies exist.

However there are well established sources of information going back many years that indicate that different populations respond in different ways to traumatisation. This doesn't mean that PTSD for example is specifically different in Africa

Hussein Ali, Sweden.

If Dr Frank is a good African doctor, he should help the continent's rulers. Because, they are all psychopathic maniacs of power. They are worse than the continents colonial powers.

Dr. Njenga:
The relationship between mental illness and bad political leadership has been raised by many of you, and several Presidents have attracted specific mention in this regard.

Inherent in all the questions in this regard is the consequence of anger and frustration expressed frequently by the citizens of these countries united in their desire to change what they perceive as an unfair political system.

Mental illness is, in this context, used as a reason or excuse for the bad leadership in these African presidents.

The reality however is that in most of these instances, a formal diagnosable mental disorder is not the culprit.

It's more probable that greed, and other consequences of social deviations are more appropriate explanations for the behaviour observed which often leads to pain, suffering and anguish of citizens.

However, it is impossible to generalize about African Heads of State in this area in either respect, without carrying out a formal examination of their mental states.

However, in my view and judging only from media reports, none of them mistreat their citizens because of mental illness and one would have to find other reasons and or excuses for their bad systems of government in some instances.

Remember however, bad governance is not always a simple matter to define, as different societies may manage their political systems in ways that others might find inexcusable.

Arthur, a Sierra Leonean in the USA

My mother is suffering from Alzheimer┐s' disease.
I grew up watching the older folks in my village living with this illness but I didn't know what it was.
My mother's was diagnosed while living with us in the USA.
What could we do in Africa to help people like my mother?
How could we make the populace be aware of this illness?

As a young boy in Africa, my relations suffering from this condition were entertaining to me.
Now that I have come to full grip with the situation, I know something has to be done.
Where can we find help ?

Dr. Njenga:
Alzheimer┐s' disease is a rapidly growing epidemic the world over.
Because the world population is growing older as people live longer, the prevalence of Alzheimer┐s' disease is increasing and Africa is no exception in this respect. Because of rapid urbanization and the breaking down of pre-existing social support systems, older people who previously enjoyed a high level of support from their sons, daughters and other members of the extended family, now find themselves exposed to the various vagaries of social insult in the absence of social support. Sufferers of Alzheimer┐s' disease are conspicuous sufferers of this social disintegration.

The Association of African Psychiatrists and Allied Professions together with other national psychiatric associations are making special and specific activities to increase knowledge on Alzheimer┐s' disease as a condition that is to be humanely dealt with. The current series of programs will in the course of time teach on this condition.